Summary On the evening of 16June2004, the PersistenceI sailed from Baie-du-Renard, Quebec, on Anticosti Island, Quebec, on a course to Natashquan, Quebec. En route, the seawater circulation system for the live-well tanks was started to preserve the catch. After a few hours under way, the operator noticed that the fishing vessel was not handling as usual. Upon conducting an inspection, he discovered that the after part of the vessel had settled lower in the water and that water had flooded into the aft compartments. The operator broadcast an urgency communication prefixed PAN PAN. The Marine Communications and Traffic Services at Rivire-au-Renard, Quebec, received the message and transmitted a Mayday Relay. A search and rescue operation was launched that included a Canadian Coast Guard ship (CCGS), and a Canadian Forces aircraft and helicopter. The CCGS CapdeRabast and the Violaine.C.I located the PersistenceI and escorted it to Natashquan. Although the afterdeck was gradually sinking below the surface, the operator managed to reach port at Natashquan and to beach the vessel near the wharf at 0525 eastern daylight time on June17. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The PersistenceI is a decked fishing vessel, built of composite materials, that is used primarily for crab fishing. The hull is divided into four compartments that are separated by three transverse bulkheads (seeAppendixA). Starting from the bow, it consists of the crew's messroom, the engine room, the fish hold, and the aft compartment, which includes a live-well tank on either side of the lazarette. The main deck has a superstructure that houses the wheelhouse at the front. The fishing vessel is also fitted with a seawater circulation system for the live-well tanks, a bilge pumping system, and a water level alarms system. Access to the afterdeck, from the wheelhouse, is through a hinged door with a sill of about 25mm, although regulations require a minimum of 300mm. History of the Voyage On 15 June 2004, the fishing vessel PersistenceI sailed from the wharf at Natashquan, Quebec, for fishing area12B with six crew members including the operator (seeFigure1). After catching 5100kg of crab on June16, the vessel left the fishing area and headed for Natashquan. During the return voyage, the operator received a request from the company to call at Anticosti Island before returning to Natashquan. Consequently, around 1830 eastern daylight time,2 at Baie-du-Renard (AnticostiIsland), an aluminum launch, two outboard motors, and 590kg of lobster distributed in 13crates were loaded, and three company employees boarded. Figure1. Appoximate route followed by the PersistenceI Soon after leaving, the crates of lobster were stowed in the port live-well tank and the seawater circulation system was started to preserve the catch. During the evening, the operator inspected the afterdeck and everything seemed normal. On 17 June 2004, around 0030, in calm seas, the operator, who was in the wheelhouse, noticed a change in the vessel's handling. He went to the afterdeck and noticed that the vessel had a pronounced trim by the stern. The water level alarm had not sounded in the wheelhouse. He proceeded forward and turned off the seawater circulation system for the live-well tanks and then returned to the lazarette to close the discharge valves. Upon opening the lazarette hatch, he saw that the compartment had flooded and that he could not access the discharge valves. From the wheelhouse, the operator ordered the crew to put on their immersion suits and to gather on the forecastle. At 0100, the operator broadcast an urgency call prefixed PANPAN to the Marine Communications and Traffic Services (MCTS) at Rivire-au-Renard, on channel16 very high frequency (VHF), and informed them that the PersistenceI was located in 4949.51'N, 06151.95'W, north of Anticosti Island, and immediate assistance was required. At 0108, the MCTS broadcast a Mayday Relay. The crew members gathered on deck and carried the liferaft to the forecastle in preparation to evacuate. At 0128, the CCGS CapdeRabast sailed from Havre-Saint-Pierre, Quebec, to the PersistenceI. Hercules aircraft R323and Cormorant helicopter R908 from Greenwood, Nova Scotia, were dispatched to the site. Meanwhile, the operator used the satellite telephone to inform the company's fishing director of the situation. The director requested the fishing vessel Violaine.C.I to assist the PersistenceI. Around 0130, the Violaine.C.I sailed from Natashquan to meet the PersistenceI. Upon rendez-vous around 0320, the operator of the PersistenceI requested the Violaine.C.I to come alongside to effect crew transfer. However, the operator of the Violaine.C.I rejected this approach on the grounds that the fishing gear would interfere with the safe execution of the manoeuvre. It was then decided to launch and use the PersistenceI's seven-person liferaft to transfer the crew. To carry out this manoeuvre, the PersistenceI's current speed, estimated at about four knots, was maintained to prevent the vessel's stern from sinking further into the water. The crew of the PersistenceI deployed the liferaft, but it capsized. In the prevailing conditions, the crew experienced difficulty in holding onto the liferaft painter and it was let go. The liferaft drifted away and it was later recovered by the Violaine.C.I. The plan to transfer the crew was now abandoned. At some point, the fish hold hatch cover was lost overboard. Photo1. The PersistenceI reaches the approaches to the Natashquan River Around 0345, the Hercules aircraft R323 arrived at the site and flew over the sector. Around 0418, the PersistenceI reached the approaches to the Natashquan River, and at 0437, the CCGS CapdeRabast arrived on scene. Upon arrival on scene and with the situation under control, the commanding officer of the CCGS CapdeRabast informed the helicopter pilot that their services were no longer required. The helicopter returned to base. Because the afterdeck was completely submerged, it was felt that towing was not appropriate. The CCGS CapdeRabast approached on the port shoulder of the PersistenceI and seven of the nine people transferred to the CCGS CapdeRabast. The operator and one crew member stayed aboard to pilot the PersistenceI. The captain of the CCGS CapdeRabast called off the mission of the R323aircraft and requested the Violaine.C.I to continue its escort into port. The crew member who stayed with the vessel gave the operator an immersion suit, supplied by the CCGS CapdeRabast. Around 0525, the operator headed the vessel onto a cay3 about 15m north of the Natashquan wharf. The vessel was successfully beached. The discharge valves in the lazarette were immediately closed, and a submersible pump was installed. Around 0620, the PersistenceI was refloated, and at 0630, it was moored to the wharf. Safety Culture Among Fishers Reporting and investigating marine occurrences to determine causes and contributing factors is one of the means of enhancing safety and indicates a positive safety culture. In the case of the PersistenceI, similar occurrences took place in spring 2002 and again in May 2004 when the fish hold flooded after the seawater circulation system for the live-well tanks was started. Neither of these occurrences were investigated by the company and the first occurrence was not reported to authorities. The lack of a safety culture among fishers has been noted in a number of TSB reports.4 In2003, the Board recommended that Transport Canada, in coordination with Fisheries and Oceans Canada, fisher associations and training institutions, develop a national strategy for establishing, maintaining and promoting a safety culture within the fishing industry. (M03-02, issued September2003) It is recognized that the attitudes toward and beliefs about risk form the basis of an effective safety culture. However, developing this safety culture will require a long-term effort to promote positive attitudes toward safety within the fishing community. In the interim, fishers will continue to be at risk. To mitigate the risk, the Board issued a second recommendation (in the same year) that The Department of Transport, in collaboration with the fishing community, reduce unsafe practices by means of a code of best practices for small fishing vessels, including loading and stability, and that its adoption be encouraged through effective education and awareness programs. (M03-07, issued November2003) Some action has been taken by Transport Canada toward developing a safety culture among the fishing community.5 Professionalization of Fishers and Fisher's Helpers in Quebec Since the Act respecting the Bureau d'accrditation des pcheurs et des aides-pcheurs du Qubec was introduced in1999, the Bureau d'accrditation des pcheurs et des aides-pcheurs du Qubec (BAPAP) has been the legal authority for professionalizing all fishers. The regulations pursuant to this Act give the BAPAP the responsibility to issue and update record books for fishers and fisher's helpers; issue certificates for fishers, fisher's helpers, and apprentice fishers attesting to the aptitude of individuals to exert their trade according to the requirements of commercial fishing; grant exemptions as required; and administer annual fees. To help achieve its objectives, the BAPAP has asked the Department of Fisheries and Oceans that issuing fishing licenses be linked to crew certification. However, to date, no concrete measures have been instituted to address this concern. The company and all crew members, including the operator, expressed interest in participating in the professionalization program for fishers and fisher's helpers; however, no action has been taken to ensure follow-up on skills and training. Policy Regarding Certificates of Competency Although Transport Canada issues fishing master certificates, they are not required for the majority of mariners whose main employment is commercial fishing as about 94percent of all fishing vessels registered are vessels with a gross tonnage of 60or less. The only training that these uncertificated mariners have to take is a Marine Emergency Duties (MED) course, and this minimum requirement will not be mandatory before2007. The Ship Station (Radio) Technical Regulations require certification to operate VHF equipment. Expertise of Personnel At the time of the occurrence, the operator had 20years of experience on fishing vessels and had been working as the operator of the PersistenceI since April2004. In February2003, he had taken the MEDA1 training, but he did not hold a fishing master certificate. All the other crew members had also taken MED training. Seawater Circulation System for the Live-well Tanks A mechanical pump located in the engine room supplies sea water to the live-well tanks, which are designed to service three tiers of lobster crates. A pipe fitted with a discharge valve, mounted on the transom at each tier level, maintains an appropriate water level in the live-well tanks. The valves, which are located in the lazarette, cannot be remotely operated (see photos2 and3). There is no physical barrier to prevent the use of this system. Photo2. Exterior view of the transom under the platform showing six seawater discharge ports connected to the live-well tanks Photo3. Interior view in the lazarette showing discharge pipes connecting the live-well tanks to the transom. Each pipe has a 76mm valve. Bilge Pumping System The bilge pumping system for the engine room comprised one hydraulically driven pump and one electric submersible pump. The fish hold is also equipped with electric submersible pumps that, together with the engine room electric pump, can be operated automatically or manually from the wheelhouse. The crew's messroom and the aft compartment are not fitted with a bilge pumping system. To dewater the aft compartment, the water is drained by gravity through three pipes and sluice valves to the fish hold (see photos4and5). Photo4.View in the fish hold showing drain pipe for the starboard live-well tank(A), the lazarette(B), and the port live-well tank(C) Photo5. View in the lazarette showing sluice valves for the live-well tanks and the lazarette High Water Level Alarm System Although not required by the Small Fishing Vessel Inspection Regulations (SFVIR),6 a high water level alarm system with audible and visual warning signals is fitted in the wheelhouse. The system is powered from a circuit breaker located in the wheelhouse electrical distribution panel. Alarm detectors are installed in the lazarette, fish hold, and engine room. Following the occurrence, the system was tested. Contrary to its design, the alarm remained activated although the compartments were dry. Inspection Regime for Small Fishing Vessels The SFVIR govern construction and inspection of small fishing vessels to ensure that they remain seaworthy. The inspection program includes the following steps: submission in triplicate of documents related to the vessel (more often than not in the form of plans) to a Transport Canada (TC) Centre; review of the documents by the Marine Safety Branch at a TC Centre (approved documents will bear a seal of certification and approval); inspection during construction and follow-up testing of the vessel by an inspector from TC's Marine Safety Branch to ensure compliance with the approved plans; and issue of an inspection certificate by a TC inspector once all the regulatory provisions applicable to the vessel have been met. In this instance, on 29April1998, the builder submitted generic plans for the construction of a class of hull to the TC Centre in the Atlantic region, and these were used for the construction of the PersistenceI. Those plans included a plan of the longitudinal section, beams and framework, details and laminating, and details. On 09 July 1998, the Technical Services Division at the regional TC Centre approved the documents subject to notations in red. A review of the plans showed these items among those notations: Additional information required by Schedule1 of the SFVIR to be submitted. Bulkhead between the fish hold and the aft compartment must be watertight. A copy of the plans was submitted to the builder and another was submitted to the TC Centre in the district where the PersistenceI was built and inspected. This district is subdivided into four sectors with one inspector assigned to each sector. Since the inspectors have various specialties, vessels under construction are sometimes inspected by an inspector whose primary expertise does not correspond to the aspect of construction being inspected. During construction in2001, the shipyard submitted a proposal to TC to fit out live-well tanks. TC responded by mail to the shipyard that such an addition would require an inclining experiment and the presentation of a stability booklet for approval. These conditions were not followed up. On 09 July 2001, construction of the PersistenceI was completed with the fitting out of live-well tanks. The inspector issued an Inspection Certificate for a Commercial Fishing Vessel valid until 08July2005 with an annotation in English prohibiting the operator from using the live-well tanks. On 02 October 2001, TC again notified the owner by mail that the live-well tanks should not be used unless the adequacy of the stability had been shown. On 16 October 2003, the owner made changes to the lifesaving equipment to allow the vessel to carry seven people instead of four. The inspection certificate was modified to reflect this, but the certificate was not posted on board. Transfer of Ownership The PersistenceI was operated for one season in the Maritimes region until it was purchased by the Regroupement Mamit Innuat inc. on 01May2002. The information concerning the transfer was entered in the Ship Registration Information System by the registrar at the TC Centre in Qubec, Quebec, but the Marine Safety Branch in Qubec was not aware of the transfer.